Documente Academic
Documente Profesional
Documente Cultură
BY:
Dion Pratama
Rahmat N. Yuda Putra
Preseptor:
Dr. Yaslinda Yaunin, Sp. KJ
Name : Mr. RA
Gender : Male
Age ` : 23 years old.
Marital status : Single
Address : Sungai Sapih, Padang,
West Sumatera
Occupation and School : Work as goat milker / SMK
Religion : Islam
Citizen : Indonesian
Race : Minangkabau
ANAMNESES
A male patient 23 years old come to Poli Jiwa RSUP
DR. M. DJAMIL Padang by himself on September 8th
2015 with the symptom is reguler control.
Main reason of Medical Check-up
Patient is single
Socio economic status
Memory : good
Concentration : good
Orientation : time, place, situation,
and person orientation is not disturbed
Knowledge : normal, average
Discriminative insight : not disturbed
Intelligence prediction : normal, average
Discriminative judgment : not disturbed
Intellectual condition of function
Sensation and Preception Abnormalities : Illusion
(-) Hallucination (-)
Axis 1.
Clinical syndrome
Specific condition :
Affective condition : hipertym, stable, echt, deep,
wide, fast
Intellectual condition of function : good memory,
good concentration, time, place, situation, and
person orientation is not disturbed, knowledge is
normal-average, discriminative insight and
judgments is not disturbed.
Sensation and perception abnormalities : no illusion,
no hallusinasion (auditory, visual, olfactory, and
tactile).
Thought process condition : clearly and sharp,
coherent
Instinctual drive and behavior abnormalities : none
Over anxiety : none
Reality testing ability : good in behavior,
thoughts, and feeling
III. No Diagnosis
Differential diagnosis
F 31.1 Bipolar Affective Disorder, current
episode manic, without psychotic symptoms
F 31.6 Bipolar Affective Disorder, current
episode mixed
Therapy
R/ Olanzapine 4 mg
Thiamin 2 mg
Piridoxine 2 mg
Mf pulv dtd No. XXX
S1dd caps I
Psychotherapy
For Patient
Supportive psychotherapy
Psychoeducation
For Family
Psychoeducation about patient
disorder
Prognosis
Clinical : bonam
Functional : bonam
Social : dubia at bonam
Case Analysist / Conclusion
The patient diagnose was found from patient medical history,
there was repeated changes of mood from 2001 until now.
Patient was talking too much, hipertym, echt, and fast
emotional flow. Patient was diagnosed with Bipolar Affective
Disorder, current episode hypomanic (F31.0), Patient was given
Olanzapine 4 mg, Tiamin 2 mg, and Piridoxine 2 mg, and
mixed into capsule. The medicine must be taken one per day in
night time.